Intracranial venous thrombosis in the first trimester of pregnancy

Cerebral venous thrombosis as a rare cause of nausea and vomiting in early pregnancy: Case series in a single referral center and literature review

Objectives

Cerebral venous thrombosis (CVT) in early pregnancy is extremely rare and evidence limited to only a few published reports. This study aims to present our experience and summarize the available literature to further elucidate the clinical manifestations, treatment, and outcomes of CVT in early pregnancy.

Methods

A retrospective case series of seven patients diagnosed with CVT in early pregnancy (<12 weeks of gestations) in a tertiary referral center (2018–2021), along with a review of published literature.

Results

All the patients presented with nausea, vomiting, headaches, and neurological symptoms including aphasia (n = 5, 71.4%), limb weakness (n = 4, 57.1%), seizures (n = 2, 28.6%), altered mental status (n = 3, 42.9%), and blurred vision (n = 2, 28.6%). All the patients were diagnosed with CVT by neuroimaging, which revealed various extents of sinus involvement, with the transverse sinus being the most common site (n = 7, 100%) followed by the sigmoid sinus (n = 5, 71.4%). All the patients received subcutaneous low-molecular-weight heparin once the diagnosis was confirmed. Two patients with rapid deterioration underwent venous thrombectomy, and one patient subsequently underwent decompressive craniotomy but died despite the above interventions. All the other patients proceeded with induced abortion after stabilization and were discharged on oral anticoagulation for 1 year. On the 12-month follow-up, the MRI/magnetic resonance venography (MRV) revealed recanalization of sinuses and resolution of thrombi.

Conclusions

Cerebral venous thrombosis (CVT) in early pregnancy represents a diagnostic challenge given its rarity and nonspecific overlapping clinical features with nausea and vomiting of pregnancy/hyperemesis gravidarum (NVP/HG), which could lead to delay in diagnosis and result in rapid deterioration. Persistent or aggravating headaches combined with other focalizing neurological symptoms in NVP/HG patients could be an initial sign of CVT. Urgent MRI/MRV remains the cornerstone for diagnosis, and immediate anticoagulation is the key for disease prognosis. Glasgow coma scale (GCS) evaluation on admission is probably correlated with the prognosis. Early pregnancy combined with CVT is not a contraindication of continued pregnancy.

Endovascular recanalization of extensively-thrombosed cerebral venous sinuses in early pregnancy: A case report

RATIONALE

The incidence of pregnancy-related cerebral venous sinus thrombosis (CVST) is rare, and cerebral hemorrhage caused by CVST in the early pregnancy period is even rarer. Only 3 cases of cerebral hemorrhage caused by CVST had been reported in the early pregnancy period in the literature. In this study, we reported successful endovascular treatment of such a case.

PATIENT CONCERNS

A 27-year-old woman presented with rapidly progressive neurologic decline in her second pregnancy for 8 weeks. She was afebrile and completely conscious, without neurological deficits. She did not have any previous history of venous thrombosis, hematologic, or autoimmune diseases.

DIAGNOSIS

Urgent brain computed tomography demonstrated parietal-occipital hemorrhage surrounded by a large hypodense area and full brain swelling. Magnetic resonance venography showed complete occlusion of the right sigmoid sinus, transverse sinus, and two-thirds of the superior sagittal sinus. Transvaginal sonography demonstrated early intrauterine pregnancy, with the size of gestation sac being 6 × 7 × 6 mm and the fetal heart not being detected. CVST-related cerebral hemorrhage was confirmed based on the clinical and imaging data.

INTERVENTIONS

The CVST in this pregnant woman was treated endovascularly with a 6 Fr Navien catheter for aspiration, thrombolysis, and anticoagulation.

OUTCOMES

Ten days after treatment, the cerebral hemorrhage had gradually been absorbed. Follow-up angiography performed 2 weeks later demonstrated complete recanalization of her cortical veins and sinuses. Two months later, the patient was completely recovered without cognitive or neurological dysfunction.

LESSONS

Pregnancy-related CVST can be successfully treated with a combined endovascular approach of aspiration, thrombolysis, and anticoagulation to complete recovery.

Cerebral Vein Sinus Thrombosis in Obstetrics and Gynecology Practice

Amaç. Serebral Ven Sinüs Trombozu (SVST) çok çeşitli ve nonspesifik semptomlarla kendini gösteren ve farklı etiyolojilere bağlı olarak ortaya çıkan klinik bir durumdur. Tanısı kolayca konulamayan nadir bir hastalıktır. SVST gelişen olgularda, jinekolojik ve obstetrik nedenlerin araştırılmasını amaçladık. Gereç ve Yöntemler. Fırat Üniversitesi Tıp Fakültesi Hastanesi’ne Kasım 2010 ile Kasım 2020 tarihleri arasında nörolojik şikayetlerle başvuran, yapılan değerlendirmede SVST tanısı konulan olgular ile obstetrik/jinekolojik nedenlerle SVST gelişen kadınlar, retrospektif olarak incelendi. Kadınların başvuru şikâyetleri, nöroradyolojik bulguları ve uygulanan tedaviler kayıtlardan tespit edildi. Verilerin değerlendirmesinde tanımlayıcı istatistik kullanıldı. Bulgular. Çalışmanın yapıldığı dönemde 166 olguya SVST tanısı konuldu. Olguların 105’i kadın (% 63,2) ve 61’i erkek (% 36,8) idi. 15 olguda (% 9) obstetrik ve jinekolojik nedenlere sekonder SVST geliştiği tespit edildi. En sık semptom baş ağrısı (%80) ve en sık bulgu papil ödemi (%20) ile birlikte hemiparezi (%13,3) ve hemipleji (%6,7) olarak tespit edildi. Çalışmaya dâhil edilen altı olgu (%40) puerperal dönemde idi. Bunlardan iki olgu (%13,3) vaginal yolla, dört olgu (%26,7) ise sezaryenle doğum yapmıştı. Olgulardan beş tanesi (%33,3) gebe idi. Gebelerin tamamı gebeliğin 3. trimesterinde bulunuyordu. Bir olguda (%6,7) mastoidit geliştiği ve 4 ay öncesinde vaginal yolla doğum yaptığı tespit edildi. Bir olgunun puerperal dönemde olduğu ve eşlik eden sinüzit enfeksiyonu bulunduğu (%6,7), ayrıca aile öyküsünde postpartum derin trombozu varlığı tespit edildi. İki olgunun (% 13,3) kombine oral kontraseptif (OKS) kullandığı, bunlardan birinde MTHFR homozigot mutasyon varlığı ve homosistein yüksekliği tespit edildi. Olguların tamamı değerlendirildiğinde 7 olguda (%46,7) kalıtsal trombofili tanısı mevcuttu. Sonuç. SVST olgularında gebelik, puerperal dönem ve OKS kullanımı başta olmak üzere, obstetrik ve jinekolojik nedenler %10’a yakın yer tutar ve değerlendirme sırasında göz önünde bulundurulmalıdır.

Cerebral venous sinus thrombosis with cerebral hemorrhage during early pregnancy

Cerebral venous sinus thrombosis (CVST) rarely induces cerebral hemorrhage, and CVST with cerebral hemorrhage during early pregnancy is extremely rare. Upon literature review, we are able to find only one case of CVST with cerebral hemorrhage in early pregnancy. In this paper, we report another case of a 27-year-old patient who developed CVST with cerebral hemorrhage in her fifth week of pregnancy. Although the optimal treatment for this infrequent condition remains controversial, we adopted anticoagulation as the first choice of treatment and obtained favorable results.

Severe subarachnoid hemorrhage associated with cerebral venous thrombosis in early pregnancy: a case report

BACKGROUND

Cerebral venous thrombosis (CVT) rarely induces subarachnoid hemorrhage (SAH). During late pregnancy and puerperium, CVT is an uncommon but important cause of stroke. However, severe SAH resulting from CVT is extremely rare during early pregnancy.

OBJECTIVE

We report on a rare case of severe SAH due to CVT, and discuss the potential pitfalls of CVT diagnosis in early pregnancy.

CASE REPORT

A 32-year-old pregnant woman (9th week of pregnancy) presented with slight head dullness. Initial magnetic resonance imaging (MRI) revealed focal, abnormal signal intensity in the left thalamus. Nine days later, the patient developed a generalized seizure and severe SAH was detected with computed tomography (CT) scan. MRI and cerebral angiography revealed a completely thrombosed superior sagittal sinus, vein of Galen, straight sinus, and right transverse sinus. Transvaginal sonography indicated a missed abortion. The day after admission, the patient presented again with a progressive loss of consciousness and signs of herniation. The patient underwent emergency decompressive craniotomy, followed by intrauterine curettage. Two months later, she made an excellent recovery except for a slight visual field defect.

CONCLUSIONS

A rare case of severe SAH due to CVT is reported, with emphasis on the potential pitfalls of CVT diagnosis in early pregnancy.

Hyperperfusion encephalopathies: hypertensive encephalopathy and related conditions

BACKGROUND

Hypertensive encephalopathy (HTE) is a syndrome typified by headache, seizures, and neurologic signs associated with increased systemic blood pressures; edema in the subcortical white matter is seen on imaging studies and is usually reversible, although infarction or hemorrhage may supervene. Based on previous work, we theorize that HTE is associated with increased perfusion to the brain. Syndromes related to HTE may also be encountered in clinical situations in which perfusion to the brain is acutely increased without systemic hypertension (i.e., after treatment of high-grade carotid stenoses or large intracranial arteriovenous malformations, or in high altitude mountain sickness). We therefore refer to these conditions more generally as hyperperfusion encephalopathies (HPE).

REVIEW SUMMARY

The clinical and radiographic data of 110 patients (average age, 50.1 years) who presented at the Brigham and Women's Hospital with clinical and radiographic signs of HPE were reviewed; 104 had systemic hypertension and 6 had postcarotid endarterectomy hyperperfusion syndrome. Edema involved the subcortical white matter and occasionally the cortex in all patients. In patients with systemic hypertension, the edema was usually bilateral and located predominantly in the occipital lobes; other brain regions included the parietal lobes, posterior frontal lobes, cerebellum, and splenium of the corpus callosum. The six patients with postcarotid endarterectomy hyperperfusion syndrome had edema in the hemisphere ipsilateral to the operated side involving the anterior and middle cerebral artery territories. The edema in HPE was associated with: increased low attenuation on CT; decreased T(1) and increased T(2) signal on MR imaging; increased cerebral perfusion on single emission computed tomography (SPECT) and perfusion MR imaging;did not show restricted diffusion on MR imaging. The syndrome resolved completely in most cases after the administration of antihypertensive agents, although rarely small infarcts and hemorrhages occurred. Three patients with thrombocytopenia developed large fatal intracranial hemorrhages.

CONCLUSION

The symptoms of HPE are usually nonspecific, but the radiographic findings are consistent. Treatment should be instituted rapidly and patients should be followed until the condition resolves either clinically or radiographically; hemorrhagic complications, although rare, can be serious.

Contrast-enhanced MR imaging of dural sinus thrombosis: demonstration of the thrombosis and collateral venous channels

In order to study the role of Gd-DTPA-enhanced MR imaging in dural sinus thrombosis, precontrast and postcontrast imaging using Gd-DTPA in three patients with clinically unsuspected dural sinus thrombosis was reviewed. Comparisons were made with cranial CT scanning and cerebral angiography. Compared to CT, the postcontrast T1-weighted images more clearly revealed thrombus in the dural sinuses as a nonenhanced central area of intermediate intensity (but not flow void) surrounded by an enhanced rim. MR imaging also demonstrated secondary changes, including the presence of collateral venous channels and venous infarction.

Eosinophilic granuloma of the occipital bone presenting as intracranial venous hypertension

Intracranial venous sinus thrombosis is an uncommon cause of pseudotumor cerebri. The diagnosis is often not confirmed on the rationale that treatment will not be altered. We report a case presenting a pseudotumor cerebri where the underlying pathology disclosed dural sinus thrombosis resulting from compression by an eosinophilic granuloma of the occipital bone. Routine CT of the head and Technetium-99m brain scan initially demonstrated neither tumor nor thrombosis. Plain skull x-rays subsequently revealed a lytic lesion of the occiput. When reinvestigated with CT using bone density windows the tumor was revealed. Excision of the tumor and a short course of cobalt therapy was curative. Special techniques in nuclear scanning, CT and MRI designed to improve the sensitivity for diagnosing venous sinus thrombosis are described. This case illustrates the importance of establishing a definitive diagnosis and shows the importance of pre-test consultation between clinicians and radiologists to ensure that specific investigative techniques are properly utilized.

"Pseudo-delta sign" on computed tomography in an extremely acute stage of superior sagittal sinus thrombosis--a case report

A case of superior sagittal sinus (SSS) thrombosis with a "pseudo-delta sign" on computed tomography (CT) is reported. The so-called "empty delta sign," which usually appears following contrast enhancement, is reliable in the CT diagnosis of SSS thrombosis but may not appear, it is said, in the extremely acute stage. In this patient, however, the "empty delta sign" appeared with precontrast CT scans and disappeared with postcontrast CT scans, "pseudo-delta sign," in the extremely acute stage of SSS thrombosis. On the precontrast CT, blood surrounding the sagittal sinus outlined it; when contrast was given, it became dense with blood.

Hereditary antithrombin III deficiency with a superior sagittal sinus thrombosis: evidence for a possible mutation starting in the mother of the propositus

A patient with a superior sagittal sinus thrombosis (SSST) which occurred during the postpartum period is reported. Coagulation studies revealed persistently decreased antithrombin III (AT III) activity. Studies of AT III activity in her family revealed a hereditary AT III deficiency. Since AT III activity was normal in the grandparents of the propositus, the disorder in this family appears to be due to a spontaneous mutation occurring in the mother of the propositus.

Superior sagittal sinus thrombosis. Still a killer

Following treating a case of superior sagittal sinus thrombosis, we did an extensive search of the literature, eliciting 795 cases of the disorder. An analysis showed that even after the introduction of antibiotics, the preponderance of these cases have been diagnosed at autopsy. Our findings raise questions about the current methods of diagnosis and management of superior sagittal sinus thrombosis: Can the correct diagnosis be made earlier? Does a distinction between partial and complete thrombosis call for a different management?

Brain swelling and ventricle size

Cerebral ventricle size was measured in one hundred normal people, age 10 to 50 years. The measurements were obtained from computed tomographic (CT) scan examinations, using the Huckman (1975) method. Normal ventricles were significantly bigger at age 45 than at age 15. These normals were compared to groups of patients with pseudotumor cerebri, water intoxication and cerebral edema, and cerebral hypoxia and edema due to cardio-respiratory arrest. The relative ventricular size was the same in the normal group and all three disease groups. Measurement of ventricle size from CT scan images is not even a crude index of cerebral edema in these three diseases.

Morphological changes in the brains of female patients who died in connection with pregnancy or delivery

The authors examined 23 brains of female patients who died during pregnancy or after delivery. Four clinical groups were distinguished: 1. sepsis, 2. gestosis, 3. patients with cardiac diseases, 4. other cases of death. General autopsy on all the dead patients was performed. Macroscopically the brain revealed the signs of oedema and herniationes. Microscopic findings showed in the sepsis and gestosis groups, distinct changes in small blood vessels. Their walls were often statified and impregnated with fibrin. In the cases with the DIC syndrome microthrombosis could be seen. Only in 2 patients cerebral arterial occlusion was noted. Neurons revealed the secondary changes described as anoxic encephalopathy.